burns burns. objectives incidence and patterns of burn injury incidence and patterns of burn injury...
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BurnsBurns
ObjectivesObjectives
Incidence and patterns of burn injuryIncidence and patterns of burn injury Pathophysiology of local and systemic Pathophysiology of local and systemic
responses to burn injuryresponses to burn injury Classify burn Classify burn Physical exam of the burned patientPhysical exam of the burned patient Prehospital management of burned patientPrehospital management of burned patient Signs and symptoms of inhalational injury Signs and symptoms of inhalational injury
which may influence managementwhich may influence management Criteria for transport to a Burn CenterCriteria for transport to a Burn Center
Incidence and Pattern of Burn Incidence and Pattern of Burn TypesTypes
Tissue injury caused by thermal, electrical, Tissue injury caused by thermal, electrical, radiation or chemical agentsradiation or chemical agents
Burns are another form of traumaBurns are another form of trauma Associated with high mortality, lengthy Associated with high mortality, lengthy
rehabilitation.rehabilitation. Greater than 2 million people/yr. seek care Greater than 2 million people/yr. seek care
for burns.for burns. Morbidity and Mortality follow significant Morbidity and Mortality follow significant
patterns regarding gender, age, and patterns regarding gender, age, and socioeconomic status socioeconomic status
SkinSkin
Largest body organ.Largest body organ. Not a passive organ.Not a passive organ.
– Protects underlying tissues from injuryProtects underlying tissues from injury– Temperature regulationTemperature regulation– Acts as water tight sealActs as water tight seal– Sensory organSensory organ
Very young and old have thin skin thus Very young and old have thin skin thus short contact time = greater damage short contact time = greater damage when compared to mid aged personswhen compared to mid aged persons
Skin concerns after burnsSkin concerns after burns
InfectionInfection
Problems with thermal regulationProblems with thermal regulation
Inability to maintain normal water Inability to maintain normal water balancebalance
Skin layersSkin layers
Two layers Two layers – EpidermisEpidermis– DermisDermis
EpidermisEpidermis– Outer cells are deadOuter cells are dead– Protective barrier and Protective barrier and
water tight sealwater tight seal– Deeper layers contain Deeper layers contain
pigment to protect pigment to protect against UV radiation against UV radiation and produce stratum and produce stratum corneumcorneum
Skin LayersSkin Layers
DermisDermis– Consists of tough, Consists of tough,
elastic tissue which elastic tissue which contains specialized contains specialized structures such as structures such as hair follicles, sweat hair follicles, sweat glands, blood glands, blood vessels, oil glands, vessels, oil glands, and nerve endingsand nerve endings
Burns
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Burn Types
• Thermal (exposure to heat)– Examples: flame, scald, flash
• Chemical– Examples: acids, alkalis
• Electrical (including lightning)
• Radiation
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Burn Severity
• Depth• Extent• Location• Patient age• Conditions present
before the burn• Associated factors
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Burn Depth
• Superficial (first-degree) burn
• Partial-thickness (second-degree) burn
• Full-thickness (third-degree) burn
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Depth of burn
Partial thickness Partial thickness burn =burn =
involves epidermisinvolves epidermis
Deep partial Deep partial thickness =thickness =
involves dermisinvolves dermis
Full thickness =Full thickness =
involves all of skininvolves all of skin
Classification of BurnsClassification of Burns
First degree / First degree / superficial burn- superficial burn- painful, red, and painful, red, and dry and blanch dry and blanch with pressure. with pressure.
Superficial (First-Degree) Burn
• Involves only epidermis
• Minor tissue damage
• Skin red, tender, very painful
– No blistering
• Does not usually require medical care
• Heals in ~2 to 5 days
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Superficial (First-Degree) Burn
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Partial thickness burns
Sunburn is a very superficial burn.Sunburn is a very superficial burn. Expect blistering and peeling in a few days.Expect blistering and peeling in a few days. Maintain hydration orally.Maintain hydration orally. Heals in 3-6 days- generally no scaring Heals in 3-6 days- generally no scaring Topical creams provide relief. Topical creams provide relief. No need for antibioticsNo need for antibiotics
Partial-Thickness (Second-Degree) Burn
• Extends through epidermis into dermis
• Intense pain
• Some swelling
• Blistering may be present
• Skin pink, red, or mottled
• Heal in ~5 to 35 days
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Classification of BurnsClassification of Burns
22ndnd degree / partial degree / partial thickness burn- thickness burn- characterized by characterized by blisters, injury blisters, injury extends through extends through the dermis to the the dermis to the epidermis, basal epidermis, basal layers of skin are layers of skin are not destroyednot destroyed
Partial-Thickness (Second-Degree) Burn
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Deeper partial thickness
Blisters are typical of partial thickness burns.Blisters are typical of partial thickness burns. Don’t be in a hurry to break the blisters.Don’t be in a hurry to break the blisters. Heals in 14-21 daysHeals in 14-21 days Blisters provide biologic dressing and comfort.Blisters provide biologic dressing and comfort. Once blisters break, red raw surface will be very painful.Once blisters break, red raw surface will be very painful.
Full-Thickness (Third-Degree) Burn
• Destroys epidermis, dermis
• Skin color varies
• Looks dry, waxy, or leathery
• Numb – nerve endings destroyed
• Rapid fluid loss
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Classification of BurnsClassification of Burns
33rdrd degree / full degree / full thickness burns- Entire thickness burns- Entire thickness of dermis thickness of dermis and epidermis is and epidermis is destroyed. Wound destroyed. Wound characterized by characterized by coagulatin necrosis coagulatin necrosis and appears pearly and appears pearly white, charred or white, charred or leathery. Sensation leathery. Sensation and cap refill are and cap refill are absent.absent.
Full-Thickness (Third-Degree) Burn
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Deeper partial thickness
Blisters are typical of partial thickness burns.Blisters are typical of partial thickness burns. Don’t be in a hurry to break the blisters.Don’t be in a hurry to break the blisters. Heals in 14-21 daysHeals in 14-21 days Blisters provide biologic dressing and comfort.Blisters provide biologic dressing and comfort. Once blisters break, red raw surface will be very painful.Once blisters break, red raw surface will be very painful.
Mixed partial and full thickness
Central yellow area might be full thickness.Central yellow area might be full thickness. Outer edges are probably partial thickness.Outer edges are probably partial thickness. Initial management is the same.Initial management is the same. Later will need skin grafts for the full thickness areas.Later will need skin grafts for the full thickness areas.
Zones of Burn Wounds
Zone of CoagulationZone of Coagulation devitalized, necrotic, white, no devitalized, necrotic, white, no
circulationcirculation Zone of Stasis ‘circulation sluggish’Zone of Stasis ‘circulation sluggish’
may covert to full thickness, mottled may covert to full thickness, mottled redred
Zone of HyperemiaZone of Hyperemia outer rim, good blood flow, redouter rim, good blood flow, red
Wound Wound excision until excision until fine punctate fine punctate
bleeding bleeding occursoccurs
Factors which affect Burn Factors which affect Burn injuryinjury
Water contentWater content Skin thicknessSkin thickness Skin pigmentSkin pigment Presence of absence of insulating Presence of absence of insulating
substancessubstances Peripheral circulationPeripheral circulation
Tissue damage depends on Tissue damage depends on temperature and timetemperature and time
Surface temperature of 44 C (111 F) Surface temperature of 44 C (111 F) begins to produce burns. But is dependent begins to produce burns. But is dependent on exposure time.on exposure time.
Temperature >44C and < 51C (124F) the Temperature >44C and < 51C (124F) the rate of epidermal necrosis doubles with rate of epidermal necrosis doubles with each degree of temperature increase.each degree of temperature increase.
At > 70 C (185F) or greater, exposure time At > 70 C (185F) or greater, exposure time required to cause transepidermal necrosis required to cause transepidermal necrosis is less than 1 second.is less than 1 second.
Normal process of water evaporation is Normal process of water evaporation is accelerated 5 to 15 time to that of normal accelerated 5 to 15 time to that of normal skin.skin.
Pathophysiology of BurnsPathophysiology of Burns(Local response)(Local response)
Based on Jackson’s Based on Jackson’s thermal wound theorythermal wound theory
Zone of hyperemiaZone of hyperemia– Increased blood flow due Increased blood flow due
to normal inflammatory to normal inflammatory responseresponse
Zone of stasisZone of stasis– Potentially viable tissuePotentially viable tissue– Cells are ischemic due to Cells are ischemic due to
clotting and clotting and vasoconstrictionvasoconstriction
Zone of coagulationZone of coagulation– Coagulation necrosis has Coagulation necrosis has
occurredoccurred– Tissue is non viableTissue is non viable
Extent of BurnKey Points
• Only partial-thickness and full-thickness burns are included when calculating extent of a burn
• Extent of the burned area is important to determine– The depth of the burn must also be considered, although
superficial burns are not included in the calculation of the extent of a burn
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Extent of BurnRule of Nines
• “Rule of Nines”– Guide used to estimate body surface area
burned– Divides adult body into 9%, or multiples of
9%, sections– Modified for children and infants
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Extent of BurnRule of Nines
Body Area Adult Child Infant
Head and neck 9% 18% 18%
Front of trunk 18% 18% 18%
Back of trunk 18% 18% 18%
Each arm (shoulder to fingertips)
9% 9% 9%
Each leg (groin to toe) 18% 13.5% 13.5%
Genitals 1% 1% 1%
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Extent of BurnRule of Nines
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Extent of BurnRule of Palms
• “Rule of Palms” can be used for:– Small or irregularly shaped burns– Burns scattered over the body
• Palm of patient’s hand equals 1% of patient’s body surface area
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Burns Best Treated in a Burn Center
• Second-degree burns involving over 10% total body surface area (TBSA) in adults or 5% TBSA in children
• Chemical burns• All burns involving hands, face, eyes, ears, feet, or
genitals• Circumferential burns of the torso or extremities• Any third-degree burn in a child• All inhalation injuries• Electrical burns, including lightning injury• All burns complicated by fractures or other trauma• All burns in high-risk patients including older adults, the
very young, and those with preexisting conditions such as diabetes, asthma, and epilepsy
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Care of small burns
What can YOU do?
Care for Thermal Burns
• If patient still in area of heat source, move to safe area
• If clothing is in flames – stop, drop, and roll
• Remove smoldering clothing and jewelry– Cut around areas where clothing is
stuck to skin
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Primary Survey
• Stabilize cervical spine if needed
• Was the patient in a confined space and exposed to smoke, flames, or steam?– How long was he exposed?– Did he lose consciousness?– Were hazardous chemicals involved?
– Be alert for potential airway problems
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Burn injuriesBurn injuries(Primary Survey)(Primary Survey)
Recall that burn patients are first and Recall that burn patients are first and foremost trauma patientsforemost trauma patients
CirculationCirculation AirwayAirway BreathingBreathing DisabilityDisability ExposureExposure
AirwayAirway
Airway controlAirway control– Chin liftChin lift– Jaw thrustJaw thrust– Insert oral Insert oral
pharyngeal airwaypharyngeal airway– Assess need for ET Assess need for ET
intubationintubation Maintain in-line Maintain in-line
cervical cervical immobilization in immobilization in patients at riskpatients at risk
BreathingBreathing
Listen: verify breath soundsListen: verify breath sounds Assess rate and depth of respirationsAssess rate and depth of respirations Administer high flow O2Administer high flow O2 Monitor chest wall excursion in Monitor chest wall excursion in
presence of full thickness torso burnspresence of full thickness torso burns
Inhalational injuryInhalational injury
Present in 10 – 20 % of burn patientsPresent in 10 – 20 % of burn patients Identified in 60 – 70 % of patients Identified in 60 – 70 % of patients
who die in burn centerswho die in burn centers
Inhalation Injury
• Facial burns• Soot in the nose or mouth• Singed facial or nasal hair• Swelling of lips or inside
mouth• Coughing• Inability to swallow
secretions• Hoarse voice
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Airway assessment and Airway assessment and managementmanagement
Humidified 100% O2 by maskHumidified 100% O2 by mask Endotracheal intubation indicated ifEndotracheal intubation indicated if
– Airway obstruction imminent as signaled Airway obstruction imminent as signaled by progressive hoarseness and/or stridorby progressive hoarseness and/or stridor
– LOC is such that airway protective LOC is such that airway protective reflexes are imparedreflexes are impared
Warning signs/cluesWarning signs/clues
Facial burns, singed nasal hairsFacial burns, singed nasal hairs Carbonaceous sputumCarbonaceous sputum Tachypnea, intercostal retractionsTachypnea, intercostal retractions HoarsnessHoarsness Agitation (hypoxia)Agitation (hypoxia) Rales, rhonchi, diminished breath Rales, rhonchi, diminished breath
soundssounds Inability to swallowInability to swallow Naso or oro-pharynx erythemaNaso or oro-pharynx erythema
CirculationCirculation
Monitor BP, pulse rate, skin colorMonitor BP, pulse rate, skin color Establish IV accessEstablish IV access
– If possible, place iv in non-burned skin, If possible, place iv in non-burned skin, but may place it in burned skin if but may place it in burned skin if needed.needed.
– How would you secure IV in burned How would you secure IV in burned tissue?tissue?
Assess circulatory status of Assess circulatory status of circumferentially burned extremitiescircumferentially burned extremities
Disability, Neurologic Disability, Neurologic DeficitsDeficits
Typically alert and oriented. If not, Typically alert and oriented. If not, why not?why not?
Remember AVPU?Remember AVPU?– A-AlertA-Alert– V-Responds to verbal stimuliV-Responds to verbal stimuli– P-Responds to painful stimuliP-Responds to painful stimuli– U-UnresponsiveU-Unresponsive
Disability, Neurologic Disability, Neurologic DeficitsDeficits
Please remember before you Please remember before you intubate, if possible, to get any intubate, if possible, to get any pertinent historypertinent history– AMPLE historyAMPLE history– A – AllergiesA – Allergies– M – MedicationsM – Medications– P – Previous medical/surgical historyP – Previous medical/surgical history– L – Last meal (time)L – Last meal (time)– E – Events/environment surrounding the E – Events/environment surrounding the
injury; ie. Exactly what happenedinjury; ie. Exactly what happened
Exposure/Environmental Exposure/Environmental controlcontrol
First must remove patient to a safe First must remove patient to a safe areaarea
Stop the burning processStop the burning process– Exstinguish fire – cool smoldering areasExstinguish fire – cool smoldering areas– Remove ALL clothing and ALL jewelryRemove ALL clothing and ALL jewelry– Cut around areas where clothing is stuck Cut around areas where clothing is stuck
to the skinto the skin– Cool adherent substances (Tar, Plastic)Cool adherent substances (Tar, Plastic)
Exposure/Environmental Exposure/Environmental controlcontrol
Once patient in safe areaOnce patient in safe area Maintain patient’s temperatureMaintain patient’s temperature
– Warm room or rigWarm room or rig– Keep patient covered; dry sheets, Keep patient covered; dry sheets,
blanketsblankets– Warm IV fluidsWarm IV fluids
Circumstances of Circumstances of InjuryInjury
Circumstances of Injury: Circumstances of Injury: FlameFlame
How did it occur?How did it occur?– Inside or outside?Inside or outside?– Clothing ignition?Clothing ignition?– Time to extinguish flame?Time to extinguish flame?– Extinguished how?Extinguished how?– Gasoline or other fuel involved?Gasoline or other fuel involved?– Explosion? Patient thrown?Explosion? Patient thrown?– Are purported circumstances of injury Are purported circumstances of injury
consistent with burn characteristics?consistent with burn characteristics?
Circumstances of Injury: Circumstances of Injury: FlameFlame
Structure fire?Structure fire? Smoke filled space?Smoke filled space? Others injured or killed in event?Others injured or killed in event? Was there LOC at the scene?Was there LOC at the scene? How did the patient escapeHow did the patient escape
– Did the patient jump? How far was the Did the patient jump? How far was the drop?drop?
– Through glass?Through glass?
Circumstances of Injury: Circumstances of Injury: FlameFlame
Automobile crash?Automobile crash? How badly was the car damaged?How badly was the car damaged? Other injuries?Other injuries? Did they hit anybody? Check around, Did they hit anybody? Check around,
under the vehicle.under the vehicle. Car fire?Car fire?
Circumstances of Injury: Circumstances of Injury: ScaldScald
What is the history of the injury?What is the history of the injury?– What was the liquid?What was the liquid?– What was the volume of liquid involved?What was the volume of liquid involved?– What was the temperature of the liquid? What was the temperature of the liquid?
If tap water, what was the heater temperature If tap water, what was the heater temperature setting?setting?
If heated by other source, was the liquid boilingIf heated by other source, was the liquid boiling
– Was the patient wearing clothing?Was the patient wearing clothing?– How quickly was it removed?How quickly was it removed?– Was the burned area cooled?Was the burned area cooled?– Was other first aid administered?Was other first aid administered?
Circumstances of Injury: Circumstances of Injury: ScaldScald
Is abuse or neglect Is abuse or neglect suspected?suspected?– How quickly was How quickly was
care sought?care sought?– Where did the burn Where did the burn
occur?occur?– Who was with the Who was with the
patient when the patient when the injury occurred?injury occurred?
– Does the story fit Does the story fit the injury?the injury?
Circumstances of Circumstances of Injury:ChemicalInjury:Chemical
Circumstances of Circumstances of Injury:ChemicalInjury:Chemical
What was the agent?What was the agent? Is it still around? Vapor?, Liquid?, Is it still around? Vapor?, Liquid?,
Solid?Solid? How did the exposure occur?How did the exposure occur? What was the duration of contact?What was the duration of contact? What decontamination occurred?What decontamination occurred? Was there an explosion? Was the Was there an explosion? Was the
patient thrown?patient thrown? What is the toxicity of the agent?What is the toxicity of the agent?
Chemical Burns
• Degree of injury is based on:– Mechanism of action of the chemical– Strength of the chemical– Concentration and amount of the chemical– How long the patient was in contact with the
chemical– Body part in contact with the chemical– Extent of tissue penetration
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Care for Chemical Burns
• Scene size-up– Gloves, eye protection, other PPE as
necessary– Additional resources may be needed
before you can safely enter the area
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Care for Chemical Burns
• General impression / primary survey– Manage airway and breathing– Stabilize cervical spine if needed– Remove patient’s jewelry– Remove clothing, including shoes and
socks
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Care for Chemical Burns
• Stop the burning process– Brush off dry chemicals
• Brush chemical away from the patient
– Flush the burn with large amounts of room temperature water
• Use low pressure• Flush for at least 20 minutes
• Treat other injuries, if present
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EyeChemical Burn
• Most urgent eye injury
• Damage depends on:– Type and concentration of the chemical– Length of exposure– Elapsed time until treatment
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Early Signs of a Chemical Burn
• Pain
• Redness
• Irritation
• Tearing
• Inability to keep eye open
• A sensation of “something in my eye”
• Swelling of the eyelids
• Blurred vision
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Chemical Burn to the Eye
• Emergency care
– Ask patient to remove contact lenses, if present
– Immediately flush the eye with water or normal saline
– Continue flushing for at least 20 minutes
– Flush away from the unaffected eye
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Circumstances of Circumstances of Injury:ElectricalInjury:Electrical
What kind of current was involved?What kind of current was involved? What was the duration of contact?What was the duration of contact? Was the patient thrown or did the Was the patient thrown or did the
patient fall?patient fall? What was the estimated voltage?What was the estimated voltage? Was there LOC?Was there LOC? Was CPR administered?Was CPR administered?
Circumstances of Circumstances of Injury:ElectricalInjury:Electrical
The great pretenderThe great pretender– Small surface injuries may be associated Small surface injuries may be associated
with severe internal injurieswith severe internal injuries– Causes about 1000 deaths/yr.Causes about 1000 deaths/yr.
Electrical Burns
• Severity of an electrical injury is related to:– Amperage (current flow)– Voltage (current force)– Type of current (AC/DC)– Current pathway through the body– Resistance of tissues to current– Duration of contact
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Electrical Burns
• Skin normally resists the flow of electric current into the body– Electricity entering the body is converted
to heat– Current follows paths of least resistance
• Blood vessels, nerves, muscles
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Care for Electrical Burns
• Make sure the power is off!• Contact additional resources if needed
before entering the area
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Care for Electrical Burns
• Manage ABCs
• Stabilize cervical spine if needed
• Watch closely for respiratory and cardiac arrest– Make sure an AED
is available
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Care for Electrical Burns
• Treat other injuries if present• Look for entrance and exit wounds
34-73
First contactFirst contact
After patient in safe area…After patient in safe area… Complete head to toe examComplete head to toe exam Pre-existing medical conditions? Pre-existing medical conditions?
Tetnus status? Other injuries?Tetnus status? Other injuries?
Determine Burn SeverityDetermine Burn Severity
You must assess % of body surface area You must assess % of body surface area (BSA) involved(BSA) involved
Depth of injury (1Depth of injury (1stst, 2, 2ndnd, or 3, or 3rdrd degree) degree)– Realize that this is difficult to do as burns Realize that this is difficult to do as burns
may “mature” over time AND getting an may “mature” over time AND getting an exact percentage is usually not possibleexact percentage is usually not possible
Age of patientAge of patient Associated / pre-existing disease or Associated / pre-existing disease or
illnessillness Burns to hands, face, genitalia.Burns to hands, face, genitalia.
Extent of BurnExtent of Burn
Initial estimate of 2Initial estimate of 2ndnd and 3and 3rdrd degree burns: degree burns: “rule of nines”“rule of nines”– Adult areas = 9% BSA Adult areas = 9% BSA
or multiplesor multiples– Not accurate for Not accurate for
infants/children due to infants/children due to larger BSA of head and larger BSA of head and smaller BSA of legs.smaller BSA of legs.
To estimate scattered To estimate scattered burns, palm of hands burns, palm of hands and fingers of patient and fingers of patient = 1% BSA= 1% BSA
Burn DepthBurn Depth
Very young and very old patients Very young and very old patients have thinner skinhave thinner skin
Therefore, contact time at similar Therefore, contact time at similar temperatures will be worse for them.temperatures will be worse for them.
Pre-hospital management Pre-hospital management principlesprinciples
Stop the burning processStop the burning process Universal precautionsUniversal precautions Initiate fluid resusucitation per the Initiate fluid resusucitation per the
consensus protocol:consensus protocol:– 2 - 4 ml % BSA burn2 - 4 ml % BSA burn– ½ in 1½ in 1stst 8 hrs 8 hrs– ½ over next 16 hrs½ over next 16 hrs– *this is for adults only, pediatric patients *this is for adults only, pediatric patients
require consensus formula + D5LR require consensus formula + D5LR maintenence fluidsmaintenence fluids
Pre-hospital management Pre-hospital management principlesprinciples
Vital signsVital signs
Assess extremity perfusionAssess extremity perfusion– * remove all rings, watches, other * remove all rings, watches, other
jewelryjewelry– *Elevation of burned areas if possible*Elevation of burned areas if possible
Ventilation statusVentilation status
Pain relief/managementPain relief/management
Initial Burn Wound CareInitial Burn Wound Care
Thermal burnsThermal burns– Cover with clean, DRY clothCover with clean, DRY cloth– NO ice or cold water soaksNO ice or cold water soaks
Initial Burn Wound CareInitial Burn Wound Care
Electrical InjuryElectrical Injury– Be aware of both cutaneous an internal Be aware of both cutaneous an internal
injuryinjury Entrance and exit points versus contact Entrance and exit points versus contact
pointspoints Arcing wounds vs electrical flash woundsArcing wounds vs electrical flash wounds
– Consider electrical current cardiac Consider electrical current cardiac effectseffects
Initial Burn Wound CareInitial Burn Wound Care
Chemical burnsChemical burns– Scene control Scene control – Brush powders from skin and clothesBrush powders from skin and clothes
Watch shoes and socksWatch shoes and socks
– Remove contaminated clothingRemove contaminated clothing– Flush with COPIUS amounts of waterFlush with COPIUS amounts of water– Eye irrigation if involvedEye irrigation if involved– Exposure protection for yourselves and Exposure protection for yourselves and
anyone involved with patient careanyone involved with patient care
Burn center referral criteriaBurn center referral criteria
The ABA identifies the following as The ABA identifies the following as injuries requiring a Burn Center injuries requiring a Burn Center referral:referral:– 22ndnd degree burns > 10% TBSA degree burns > 10% TBSA– Burns to face, hands, feet, genitalia, Burns to face, hands, feet, genitalia,
perineum, major Jointsperineum, major Joints– 33rdrd degree burns degree burns– Electric injury (lightning included)Electric injury (lightning included)– Chemical burnsChemical burns
Burn center referral criteriaBurn center referral criteria
Inhalational injuriesInhalational injuries Burns accompanied by pre – existing Burns accompanied by pre – existing
medical conditionsmedical conditions Burns accompanied by trauma, where Burns accompanied by trauma, where
burn injury poses greatest risk of morbidity burn injury poses greatest risk of morbidity or mortalityor mortality
Burns to children in hospitals without Burns to children in hospitals without pediatric servicespediatric services
Patients with special social, emotional or Patients with special social, emotional or rehabilitative needsrehabilitative needs
SummarySummary
Be able to assess injuriesBe able to assess injuries Be able to develop priority – based Be able to develop priority – based
plan of careplan of care Base care plan on type, extent, Base care plan on type, extent,
degree of burndegree of burn Consult with a burn center physicianConsult with a burn center physician Decide upon local treatment and Decide upon local treatment and
transport with burn center physiciantransport with burn center physician
Physical Examination
• Check pulses in all extremities– Circumferential burn can act as a
tourniquet
• After all immediate life-threats have been managed, care for the burn itself
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Physical Examination
• Quickly determine burn severity• Vital signs• Medical history• Questions related to the burn:
– How long ago did the burn occur?– How did it occur?– What was done to treat the burn before
you arrived?
34-87
Treat the Burn
• Cool the burn with cold water
• Cover burned area with a dry dressing or sheet
• Keep patient warm
– Cover with clean, dry sheets
• Remove all jewelry
• Look for other injuries
– Treat and immobilize possible fractures
– Treat soft-tissue injuries if present
– Treat shock if present
• Keep burned extremities elevated above the heart
• Transport to closest appropriate facility
34-88
Treat the Burn
• Do not apply ice, butter, oils, sprays, lotions, or ointments to a burn
• If a blister has formed, do not break it
– Loosely cover the blister with a sterile dressing
• Do not place ice or wet sheets on a burn
• Do not transport a burn patient on wet sheets, wet towels, or wet clothing
34-89
Infant / Child Considerations
• Larger BSA than adults in relation to total body size– Greater fluid and heat loss
• More likely to develop shock or airway problems than adults
• Consider possibility of abuse when treating a burned child
• Report all suspected cases of abuse to appropriate authorities
34-90
Care of small burns
Clean entire limb with Clean entire limb with
soap and water (also under nails).soap and water (also under nails). Apply antibiotic cream Apply antibiotic cream
(no PO or IV antibiotic).(no PO or IV antibiotic). Dress limb in position of function, Dress limb in position of function,
and elevate it.and elevate it. No hurry to remove blistersNo hurry to remove blisters unless infection occurs. unless infection occurs. Give pain meds as needed (PO, IM, or IV) Give pain meds as needed (PO, IM, or IV) Rinse daily in clean water; in shower is very practical.Rinse daily in clean water; in shower is very practical. GentlyGently wipe off with clean gauze. wipe off with clean gauze.
Blisters
In the pre-hospital setting, there is no In the pre-hospital setting, there is no hurry to remove blisters. hurry to remove blisters.
Leaving the blister intact initially is less Leaving the blister intact initially is less painful and requires fewer dressing painful and requires fewer dressing changes. changes.
The blister will either break on its own, The blister will either break on its own, or the fluid will be resorbed. or the fluid will be resorbed.
Blisters break on their own
Upper arm burn day 1 day 2Upper arm burn day 1 day 2
Burn “looks worse” the next day because of blisters breaking and oozing
Upper arm burn
Blisters show probable partial thickness burn.Blisters show probable partial thickness burn. Area without blister might be deeper partial Area without blister might be deeper partial
thickness.thickness.
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Debride blister using simple instruments
Medic debriding blister
After debridement
Before and after debridement
Removing the blister leaves a weeping, very Removing the blister leaves a weeping, very tender wound, that requires much care.tender wound, that requires much care.
Silver sulfadiazene
Arm burn 4 days
Arm burn 7 days – note the exudate
Foot burn debridement
Before debriding and applying cream, clean entire foot(including toes and nails).
Silver- impregnated dressings (Silverlon)
Apply wet silver dressing Apply wet silver dressing
directly on the burn.directly on the burn. Creams or dressings Creams or dressings
under the silver dressing under the silver dressing
impede the antimicrobial action.impede the antimicrobial action. Keep it moist!Keep it moist! Remove it, rinse it out, replace it on the Remove it, rinse it out, replace it on the
burn.burn.
Steps in using silver-impregnated dressings
Clean the burn and surrounding area. Clean the burn and surrounding area. Soak silver-impregnated dressing and gauze in Soak silver-impregnated dressing and gauze in STERILE WATER or BOTTLED DRINKING STERILE WATER or BOTTLED DRINKING
WATER WATER Apply silver-impregnated dressing Apply silver-impregnated dressing
(over-lapping edges are best). (over-lapping edges are best). Wrap with the moist gauze. Wrap with the moist gauze. Secure with mesh, gauze, or tape.Secure with mesh, gauze, or tape. Keep it moist with WATER, every 12h or so Keep it moist with WATER, every 12h or so
More frequent in hot arid environmentsMore frequent in hot arid environments
picsSoak silver dressings and gauze in WATER (not saline).
Apply thesilver dressing.
Wrap with moist gauze.Secure with mesh, gauze, or tape.
First few days Moisten dressing with WATER every 12h or so.Moisten dressing with WATER every 12h or so. Remove outer gauze and silver dressing every Remove outer gauze and silver dressing every
day.day.Inspect the burn. Inspect the burn. Rinse exudate off burn.Rinse exudate off burn.
Rinse exudate off silver dressing with WATER.Rinse exudate off silver dressing with WATER. Return same silver dressing to the burn.Return same silver dressing to the burn. Apply new outer gauze moistened with Apply new outer gauze moistened with
WATER.WATER.
pics Moisten with WATER q12h or so.
Moisten wellto remove it each day.Rinse it out, and put it back on the burn.
After several days
Replace silver dressing Replace silver dressing every 2 - 5 days every 2 - 5 days depending on amount of exudate, depending on amount of exudate,
cellular debriscellular debris First wet the silver dressing before removing First wet the silver dressing before removing
it.it. Don’t pull on it if it’s stuck – moisten it more.Don’t pull on it if it’s stuck – moisten it more. Apply new moist silver dressing and gauze.Apply new moist silver dressing and gauze.
QUESTIONS ABOUT SMALL BURNS?
SUMMARYSUMMARY
Describe the differences between partial and Describe the differences between partial and full-thickness burns.full-thickness burns.
Describe how to estimate the size of a burn.Describe how to estimate the size of a burn. Describe initial care of small burns.Describe initial care of small burns. Describe follow-up and post-burn care.Describe follow-up and post-burn care.
NEXT TOPIC - BURNS OF SPECIAL AREASNEXT TOPIC - BURNS OF SPECIAL AREAS
Burns of special areasof the body
Face Face MouthMouth NeckNeck Hands and feetHands and feet GenitaliaGenitalia
Face Be Be VERYVERY concerned for the airway!! concerned for the airway!! Eyelids, lips and ears often swell Eyelids, lips and ears often swell
alarmingly.alarmingly. In fact, they look even worse the next day.In fact, they look even worse the next day. But they will start to improve daily after But they will start to improve daily after
that.that. Cleanse eyes with warm water or saline. Cleanse eyes with warm water or saline. Apply antibiotic ointment or liquid tears Apply antibiotic ointment or liquid tears
until lids are no longer swollen shut. until lids are no longer swollen shut. Bacitracin cream/ointment will serveBacitracin cream/ointment will serve
Hands and feet
This is rather deep This is rather deep and might require and might require grafting. grafting.
But initial But initial management is basic.management is basic.
Dressings should not impede Dressings should not impede circulation.circulation.
Leave tips of fingers exposed.Leave tips of fingers exposed.
Keep limb elevated.Keep limb elevated.
Hands and feet Fingers might develop Fingers might develop
contractures if active contractures if active measures are not taken measures are not taken to prevent them.to prevent them.
Infant / Child Considerations
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Older Adult Considerations
• Mechanisms and severity of burn injury related to:
– Living alone
– Wearing loose-fitting clothing while cooking
– Falling asleep while smoking
– Declining vision, hearing, and sense of smell
– Slowed reaction time
– Problems with balance and/or memory
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Escharotomy
Eschar = burned skinEschar = burned skin Escharotomy = cut burned skin to Escharotomy = cut burned skin to
relieve underlying pressurerelieve underlying pressure Similar to bivalving a tight cast.Similar to bivalving a tight cast. Cut along inside and outside of Cut along inside and outside of
limb from good skin to good skinlimb from good skin to good skin Knife can be used, or cautery.Knife can be used, or cautery. Use local or no anesthesia. Use local or no anesthesia. (Full-thickness burn should have (Full-thickness burn should have
no sensation, but underlying no sensation, but underlying tissues do!)tissues do!)
Escharotomy of forearm
Incise along medial Incise along medial and/or lateral surfaces.and/or lateral surfaces.
Avoid bony Avoid bony prominences.prominences.
Avoid tendons, nerves, Avoid tendons, nerves, major vessels.major vessels.
Escharotomy Patient had escharotomy ofPatient had escharotomy of
both legs.both legs. Incisions will heal.Incisions will heal. They will not be closed by They will not be closed by
DPC.DPC. These large burns are often These large burns are often
treated by the “open” treated by the “open” technique,technique,
that is, without dressings. that is, without dressings.
Electrical burn Outer skin mightOuter skin might not appear too bad.not appear too bad.
But heat was conducted But heat was conducted along the bone.along the bone.
Causes the most damage.Causes the most damage.
Burns from inside out.Burns from inside out.
Usually requires fasciotomyUsually requires fasciotomy
Fasciotomy
Fascia = thick white covering of muscles.Fascia = thick white covering of muscles. Fasciotomy = fascia is incised (and often overlying skin)Fasciotomy = fascia is incised (and often overlying skin) Skin and fascia split open due to underlying swelling.Skin and fascia split open due to underlying swelling. Blood flow to distal limb is improved.Blood flow to distal limb is improved. Muscle can be inspected for viability.Muscle can be inspected for viability.
Dressing and Bandaging
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Dressing and Bandaging
• Dressing– Absorbent material placed directly over a
wound
• Bandage– Used to secure a dressing in place
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Dressing and Bandaging
• Functions of dressing and bandaging wounds:– Help stop bleeding– Absorb blood and other drainage from the
wound– Protect wound from further injury– Reduce contamination and risk of infection
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Dressings
• A dressing should be:
– Lint free
– Large enough to cover the wound
• Should extend beyond wound edges
– Sterile whenever possible
– Applied directly over the wound
• Do not slide it in place
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Types of Dressings
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Sterile Gauze Pads
• Loosely woven material
• Classified by size in inches– 2 x 2– 4 x 4
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Trauma Dressing
• Thick dressing• Various sizes• Two layers of gauze
with absorbent cotton in center
• Uses– Large wounds– Pad injured limb
inside a splint
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Occlusive Dressing
• Made of nonporous material• Used to cover open wound and make
airtight seal– Chest wound– Neck wound
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Nonadherent Pads
• Gauze pads with special coating• Used to cover leaking open wound but not
stick to it
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Eye Pads
• Uses:– Cover eyes after minor eye injury– Cover small wound, such as a puncture
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Bandages
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Bandages
• Applied to keep a dressing in place
• Does not have to be sterile
• Before applying to an extremity:
– Remove patient’s jewelry
– Check pulse distal to the wound
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Roller Gauze (Kling)
• Secures dressing in place– 1-inch roll for fingers– 2-inch roll for wrists, hands, feet– 3-inch roll for elbows, upper arms– 4- to 6-inch roll for ankles, knees, legs
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Roller Bandage
• Soft, slightly elastic material• Available in various widths
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Elastic Bandage
• Do not use to secure a dressing in place• May act as a tourniquet if injured area swells
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Triangular Bandage
• Large piece of muslin • When folded, can be used as a
bandage or sling
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Self-Adherent Wrap
• Elastic wrap coated with self-adhering material
• Often used as a pressure bandage
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Pressure Bandage
• Applied over a wound site to control bleeding• Cover the wound with a dressing • Apply direct pressure until the bleeding is
controlled• Secure the dressing in place with a bandage• Assess the pulse distal to a bandage
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Applying a Roller Bandage
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Applying a Roller Bandage
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Applying a Roller Bandage
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Applying a Roller Bandage
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Head or Ear Bandage
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Upper Arm Bandage
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Elbow Bandage
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Wrist or Forearm Bandage
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Knee Bandage
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Foot or Ankle Bandage
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